Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan for a resident, resulting in unmet care needs and increased frustration among other residents. The resident, a cognitively intact female with multiple diagnoses including hypertension, heart failure, kidney failure, lung cancer, depression, and anxiety disorder, was observed repeatedly yelling for help from her room without receiving attention from staff. Despite having a care plan that included 1:1 visits and activities to engage her, there was no evidence of these activities being carried out, as the resident was observed in bed without interaction or engagement from staff over several days. Interviews with Certified Nurse Aides (CNAs) revealed that the resident did not get out of bed and that they had never observed staff conducting 1:1 activities with her. The resident's yelling was noted in nurse progress notes as a daily occurrence, causing frustration and sleep disruption for other residents. The Nursing Home Administrator (NHA) acknowledged the lack of documentation in the resident's medical record regarding offered activities, which were only noted on five occasions over a 60-day period. There was also no evidence that the resident had been invited to participate in group activities or taken outside.
Plan Of Correction
Element 1: Resident 7 no longer resides in facility. Element 2: Residents in facility were reviewed to ensure their care plans were implemented appropriately to reflect activities, interests, and preferences. If missing, interests and preferences were added to care plans. Element 3: Education was provided to Activity Director and staff to ensure care plans are implemented timely to include interests. Activities staff will ensure comprehensive care plans are updated upon completing the activities assessment. Element 4: Act dir/designee will audit 10 random residents weekly to ensure activity comprehensive care plan is completed and individualized. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.